VA Quality Enhancement Research Initiative for Substance Use Disorders

Department of Veterans AffairsVeterans Health Administration (VA)

Daniel Kivlahan, Ph.D

VA Puget Sound & University of Washington

APA, New Orleans

August 11, 2006

Veterans Health Administration (VA)

- US largest integrated healthcare system

- 4.8M veterans served in FY05

- 157 medical centers

- 721 community-based outpatient clinics

- 21 regions Veterans Integrated Service Networks (VISNs)

Articles About VA’s Quality CultureArticles About VA’s Quality Culture

“ “ . . . Overall, VHA patients . . . Overall, VHA patients receive better care than receive better care than patients in other settings” patients in other settings”

Infrastructure Advantages of VA

- National systems for adminstrative data- Integrated electronic health record- Incentivized performance monitoring- Evidence-based treatment guidelines- QUERI

Quality Enhancement Research Initiative

SUD QUERI Leadership

Research Coordinator – Tom Kosten

(recently succeeded John Finney)

Clinical Coordinator – Dan Kivlahan

Implementation Coordinator – Hildi Hagedorn

Executive Committee Members from Division 50John Finney

Keith Humphreys

Rudy Moos

Jon Morgenstern

QUERI Steps

(1) Select patient populations high prevalence / high disease burden

(2) Identify E-B Guidelines/Recommendations

(3) Assess Performance Gaps

(4) Design/Implement Improvement Programs

(5) Evaluate impact on clinical outcomes

(6) Evaluate impact on health-related quality of life

FY05 Hierarchical Categories of SUD Dx*

per 1000 ~n patients

Opioid Dependence 26,800 9% 6SUD+Axis I MH Dx** 175,000 57% 36SUD Alone 105,000 34% 22

Total SUD dx 306,800 100% 64

* SUD diagnoses exclude nicotine dependence**Dual diagnosis = any DSM Axis I psychiatric disorder and either

substance abuse or dependence

Goals of SUD QUERI

(1) Improve detection and mgmt of alcohol misuse in primary care

(2) Improve retention of patients in continuing specialty care for SUD

(3) Implement effective smoking cessation treatment

(4) Improve detection and mgmt of patients with SUDs and SUD-related co-occurring disorders seen in primary care and other medical settings

(1) infectious disease (i.e., HIV, Hepatitis C)(2) psychiatric co-morbdity

From Guidelines to Performance Measures

Practices recommended by VA Guidelines Strongest and most consistent evidence Documented variation from desired

performance Measurable with explicit criteria

Goals of SUD QUERI

(1) Improve detection and mgmt of alcohol misuse in primary care

(2) Improve retention of patients in continuing specialty care for SUD

(3) Implement effective smoking cessation treatment

(4) Improve detection and mgmt of patients with SUDs and SUD-related co-occurring disorders seen in primary care and other medical settings

(1) infectious disease (i.e., HIV, Hepatitis C)(2) psychiatric co-morbidity

The Spectrum of Alcohol UseThe Spectrum of Alcohol Use

heav

y severe

cons

umpt

ion

none

none

consequences

Risky

Lower risk

Alcohol Use Disorders

Alcohol Use Disorders

Abstinence

Harmful, abuse

Problem

AlcoholismDependence

Unhealthy alcohol use

Unhealthy alcohol use

Screening Measure: AUDIT-C

1. How often did you have a drink containing alcohol in the past year?Never (0 points), less than monthly (1 points), 2-4 times a month (2 points), 2-3 times a week (3 points), 4 or more times a week (4 points)

2. On days in the past year when you drank alcohol how many drinks did you typically drink? 0 drinks (0 points), 1-2 drinks (0 points), 3-4 drinks (1 point), 5-6 drinks (2 points), 7-9 drinks (3 points), >10 drinks (4 points)

3. How often do you have 6 or more drinks on an occasion in the past year?Never (0 points), less than monthly (1 point), monthly (2 points), weekly (3 points), daily or almost daily (4 points)

(Score 0-12; screen+ > 4 for men; > 3 women)

Alcohol Screening FY04-05

Alcohol Screening Q3 FY06

Data Source Matters

Prevalence of Screen+ (n=21 VISNs)Patient Survey: 34% (95% CI 32-35%)

Chart review: 25% (95% CI 24-27%)

Discordance +patient / -chart 13%

+chart / -patient 5%

Goals of SUD QUERI

(1) Improve detection and mgmt of alcohol misuse in primary care

(2) Improve retention of patients in continuing specialty care for SUD

(3) Implement effective smoking cessation treatment

(4) Improve detection and mgmt of patients with SUDs and SUD-related co-occurring disorders seen in primary care and other medical settings

(1) infectious disease (i.e., HIV, Hepatitis C)(2) psychiatric co-morbidity

Retention in VA SUD programs

  Schaefer et al. Medical Care 2005

0

10

20

30

40

50

60

70

1 2 3 4 5 6

Months

Per

cen

t of

Pa

tien

ts

All patients

Outpatients (n=580)

Inpatients (n=298)

Initiate Psychosocial Treatment

Focus on promoting initial engagement and maintaining retention over time. This includes attention to appropriate housing and access to treatment.

3-Month Treatment Retention

01020304050

60708090

100

FY03 FY04 FY05 FY06

% C

on

tin

uit

y

Treatment Retention Variation Remains

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

FY06 YTD

Lessons Learned

Top down and bottom up Local latitude on “how” – customizing Measure carefully

Unintended consequences Gaming

Challenges

Funding implementation Mixed research/management review panels Balance rigor and relevance

Career path for junior colleagues? Identifying “essential components”

Mechanisms of behavior change Integrated care vs. condition specific Sustainability

Workload limits – panel sizes

2 Simple principles

(1) Clear and accurate feedback on performance

(2) Accessible guidance from a supervisor/coach with greater expertise and proficiency

Miller, Sorensen, Selzer, Brigham. JSAT, 2006;21:25-39

References